Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, May 01, 2013

What is health? (continued)

A synonym for the medical
enterprise in the English speaking world is “healthcare,” which you will note
has now become one word. (It was still two words when I was a child, and for a
while I corrected my students’ papers if they made it one.) So medicine – the
social institution led, at least until recently, by people possessing the
credential Doctor of Medicine – is purportedly dedicated to caring for our
health.

When people visit
physicians, they usually do so voluntarily. Presumably, they do this because
they want the physician to make them healthier, or keep them healthy. What
exactly does that mean? What are they seeking?

This question appears
simple. We use the word health all the time. Most people don’t reflect on its
meaning any more than they reflect on the meaning of “breakfast” or
“basketball.” They answer the question at the top of this post with little
thought. It’s obvious, right? Health is . . . .

Actually that’s a very tough
question. The preamble to the constitution of the World Health Organization,
written in 1946, used this definition: “Health is a state of complete physical,
mental and social well-being and not merely the absence of disease or
infirmity.” Not only that, but “the enjoyment of the highest attainable
standard of health is one of the fundamental rights of every human being.” The
second quote is chiseled into the façade of the main building of the Harvard
School of Public Health. That is definitely uplifting.

It is also completely
nonsensical. Start with the idea of “complete . . . well-being.” Do we really
want to say that we’re unhealthy if there is anything we wish for that we do
not have? And even if we can come up with a more realistic definition of
complete well-being, is there any point in proclaiming that every human being
has a right to the highest attainable standard of whatever it is? If we do
endorse such a right, it’s not just “one of the fundamental rights,” it’s the
only one, because there wouldn’t be anything left over.

We must begin by accepting
the human condition. We are all of us born with an incurable, inevitably
progressive disease which, beginning in our third decade, gradually degrades
our physical and mental capacities and is ultimately fatal. We are, in other
words, mortal, and we grow old. What is more, our initial endowments differ. If
a congenital condition deprives us of complete well-being, have we suffered a
violation of our fundamental human rights? Or is there perhaps a more
constructive way to look at that situation?

It doesn’t take much thought
to see, further, that my well-being may conflict with yours, and that determinants
of my own well-being may conflict with each other. I have the privilege of
living in a beautiful place in the country, and having a very desirable job in
the city. But this privilege is conferred by the internal combustion engine,
which spews ultrafine particles into the atmosphere that contributes to heart and
lung disease; causes crashes that kill 36,000 Americans every year and
seriously injure many more; and is changing the global climate threatening mass
extinctions and unimaginable human misery.

I could go on about this,
even write a whole book about it. But our present purposes do not demand it. People
don’t go to physicians to claim their fundamental human right to the highest
attainable standard of health. They go because they have a particular complaint
that they think may be amenable to medical intervention, which is sufficiently
disturbing to make the trouble and possible expense worth the trouble and
downsides of medical attention.